Provider Demographics
NPI:1467985515
Name:WILLMAN, SHELLI (RDN, LD)
Entity Type:Individual
Prefix:
First Name:SHELLI
Middle Name:
Last Name:WILLMAN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 RIDENOUR ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1004
Mailing Address - Country:US
Mailing Address - Phone:541-900-6989
Mailing Address - Fax:
Practice Address - Street 1:865 SE COURT AVE STE 4
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3372
Practice Address - Country:US
Practice Address - Phone:541-900-6989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10195206133V00000X
MT44685133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered